Doctoring the Mind

Is Our Current Treatment of Mental Illness Really Any Good?

Richard P. Bentall

• Publisher: NYU Press
• Year: 2009
• ISBN:
  9780814787236
• Topic: Psychology
• Subtopic: Psychopathology
• Index: Psychology

Toward the end of the twentieth century, the solution to mental illness seemed to be found. It lay in biological solutions, focusing on mental illness as a problem of the brain, to be managed or improved through drugs. We entered the "Prozac Age" and believed we had moved far beyond the time of frontal lobotomies to an age of good and successful mental healthcare. Biological psychiatry had triumphed.

Except maybe it hadn't. Starting with surprising evidence from the World Health Organization that suggests that people recover better from mental illness in a developing country than in the first world, Doctoring the Mind asks the question: how good are our mental healthcare services, really? Richard P. Bentall picks apart the science that underlies our current psychiatric practice. He puts the patient back at the heart of treatment for mental illness, making the case that a good relationship between patients and their doctors is the most important indicator of whether someone will recover.

Arguing passionately for a future of mental health treatment that focuses as much on patients as individuals as on the brain itself, this is a book set to redefine our understanding of the treatment of madness in the twenty-first century.

PART ONE

AN ILLUSION OF PROGRESS

1
A Smashing Success?

If there is one central intellectual reality at the end of the twentieth century, it is that the biological approach to psychiatry – treating mental illness as a genetically influenced disorder of the brain chemistry – has been a smashing success.

Edward Shorter, A History of Psychiatry

A dank smell pervades the small, windowless interview room whenever Peter comes to see me. I have been trying to help him for too long; the six-month period during which a clinical psychologist would normally expect to see a client passed more than a year ago. Always, it seems, we are about to make an important breakthrough.

Our meetings, first thing in the morning, always begin with the same ritual. Checking his watch as I rush through the door of the community mental health centre after my long journey from home, Peter looks at me scornfully, then cracks a smile and says, ‘Hello mate!’ Occasionally, he tries to hug me, but I discourage him from doing so, more because I worry about his poor hygiene than for fear of violating a professional boundary. He will not see me later in the day, when his hallucinatory voices often begin to torment him, driving him back to his small, untidy flat, where he uses loud music to drown them out.

A tall, likeable man in his early thirties, he might look handsome if only he could clean himself up and do something about his burgeoning stomach. His difficulties, told to me with the precision of a man who has repeated his story many times, began more than thirteen years before we met. Happily employed on a production line and the father of a baby girl, his settled life was abruptly shattered when his girlfriend announced that she no longer wanted to live with him and had found another lover. Ejected from the family home, he was forced to move into a gloomy bed-sit, sank into depression and stopped turning up for work. Eventually he lost his job and became homeless. It was while sleeping rough on the streets that he began to hear voices, which he attributed to former friends who wished to hurt him. ‘Offer him out!’ they would say; ‘Order him out!’ which he took to mean that they wanted to take him somewhere to beat him up.

There is no record of mental illness in Peter’s immediate family. Although he was sexually abused by his stepfather when he was 10 years old, apart from a few drunken brushes with the police during adolescence, there was no other indication in his earlier life that he was destined to become a psychiatric patient. On the positive side, unlike many patients with similar difficulties, he has managed to re-establish a network of friends, and enjoys warm relationships with his mother and sister. He is also on good terms with his now-teenage daughter, whom he sees regularly. Thanks to generous social security allowances he is stuck in the benefit trap: he currently has more than enough money to meet his needs and fears he will lose out if he attempts to return to work.

The original referral letter from Peter’s psychiatrist, noting that his symptoms had persisted despite more than a decade’s treatment with medication, asked if I could try cognitive behaviour therapy, a form of psychological treatment, to help him with his voices. Despite scepticism in the past about the value of psychological treatment for patients with severe mental illness, recent studies have shown that this kind of therapy can sometimes help people like Peter.¹ In our first few months together I followed the usual protocol for this kind of treatment, asking him to keep records of when his voices came and went away, questioning him about potential triggers and investigating how his beliefs about his voices might be making them more persistent. Like many patients with voices, Peter believed that they were omniscient and omnipotent,² and I did my best to challenge his belief that they were irresistibly powerful. He also believed that other people could hear his voices and might attack him as a consequence, so I suggested a ‘behavioural experiment’ in which he attempted to record his voices with a tape recorder. Observing that he was invariably very tense, and that his anxiety on anticipating the voices seemed to provoke them, I also taught him some simple relaxation techniques. Gradually, over a period of about a year, this approach seemed to work. Peter’s diary indicated that he was hearing the voices less frequently. Whereas he was previously experiencing them on a daily basis, he eventually achieved an all-time record of thirteen days without them. He began to think about the future, discussed the possibility of voluntary work and arranged to move to a more pleasant neighbourhood.

Just as I began to contemplate a discharge letter to Peter’s psychiatrist, which would have quietly boasted about what we had achieved together, things took a dramatic turn for the worse. Arriving to see me for what was planned to be one of his final sessions, he was agitated and paranoid, his eyes flickering from side to side as he told me that his voices had kept him awake for the past two nights. At the end of the session, I watched him scan his environment nervously, before mustering the courage to step out into the street. I immediately telephoned his community psychiatric nurse, a warm, supportive woman who soon afterwards went to visit him in his new flat. Her efforts to calm him were fruitless. Within a few days he was admitted to hospital for more intensive treatment.

Psychiatric wards are often frightening places. The local psychiatric unit, built about twenty years ago in the grounds of a District General Hospital and alongside a busy motorway, has long, narrow corridors and looks shabby and impersonal. The patients’ bedrooms are dark and claustrophobic. The communal areas, the dining rooms and lounges where patients sit passively watching daytime television, smell of sweat. The nurses seem to hide away in their nursing offices, gazing out at the patients through windows of toughened glass. On the open wards, where patients can come and go as they please, some make use of the occupational therapy facilities elsewhere in the hospital, others disappear on home leave so that their capacity to live in the real world can be tested, and still others languish in silent contemplation, waiting for their drugs to take effect. On the locked wards, where the more agitated patients are contained, there is a palpable atmosphere of menace, punctuated by cries and occasional violent acts by the most disturbed patients who have yet to succumb to the sedating effects of their medication. It was on just such a ward that I found Peter, cowering in his room, too frightened to come out for fear that the other patients would assault him. It was difficult to work out the extent to which his fear was justified by his new circumstances and to what extent it was a product of his imagination.

On questioning Peter, the cause of his sudden relapse quickly became obvious. Buoyed by our success together and, unknown to me or anyone else on the clinical team, he had suddenly stopped taking his drugs. Moving home, at the best of times a stressful experience, had taken its toll. While he remained in hospital it seemed impossible to do anything particularly therapeutic. Until he was released, re-medicated, some weeks later, I was reduced to dropping by occasionally to engage him in friendly conversation, in the hope of showing him that I had not forgotten him.

Although I continue to see Peter, I cannot do so indefinitely. Recently we have been experimenting with a new strategy, inspired by studies which show that Buddhist meditation techniques are useful for patients who have not responded to more traditional forms of psychotherapy.³ I have taught him to spend brief periods sitting in silence, directing his attention towards his breathing and noticing when his thoughts wander elsewhere. Most people find that these exercises help them develop some detachment from thoughts that are distressing and preoccupying. In the hope of addressing his fear of his voices, I have had Peter repeat the words, ‘Offer him out, order him out,’ over and over to himself before beginning the exercises. Over the last few months, the frequency of his voices has again decreased and he is now spending many days without them. Is it working? Is this the method we have been searching for? Peter is increasingly optimistic, and I want to be optimistic too, but experience has taught me that confidence is often a misleading sentiment. Sometimes I feel as if I am only pretending to be useful.

What is psychosis?

Peter was diagnosed as suffering from schizophrenia. According to the textbooks, patients with this disorder typically suffer from auditory hallucinations (voices of people who are not actually present) and delusions (bizarre and irrational beliefs that are resistant to counterargument). Many patients also become thought disordered on occasion, speaking incoherently, especially when distressed. In addition to these positive symptoms, so called because they are normally absent in healthy people, many patients also suffer from negative symptoms, so called because they seem to reflect a loss of normal ability. These include apathy, anhedonia (the inability to experience pleasure) and emotional flatness.

Schizophrenia is usually considered to belong to a family of illnesses in which the patient, when most severely ill, seems to loose touch with reality. These disorders, which roughly correspond to the popular understanding of madness, are collectively known as the psychoses, and are the most severe type of mental illness. They are often contrasted with the neuroses (more common and less severe types of mental illness in which the individual, although very anxious or depressed, is aware of being ill, and does not experience hallucinations and delusions) and the personality disorders (lifelong dysfunctional patterns of relating to other people).

The other main type of psychosis is bipolar disorder, which is also sometimes known as manic depression. In this condition the sufferer experiences episodes of profound depression and also episodes of either mania (periods of uncontrollable excitement and irritability, often accompanied by disordered thinking and delusions about special powers, spectacular wealth or a special mission in life) or hypomania (a less extreme mood state characterized by euphoria, excitement and impulsive behaviour). Current diagnostic systems now distinguish between bipolar 1 disorder, in which patients experience both depression and mania, and bipolar 2 disorder, in which depression and hypomania but not mania are experienced. In both cases, episodes of extreme mood are typically interspersed by periods of remission or relatively normal functioning. Unipolar depression (depression in the absence of a history of mania), when very severe, can also be accompanied by psychotic symptoms, for example auditory hallucinations that are highly critical of the patient or delusions that the individual is guilty of some kind of terrible crime. The term psychotic depression is sometimes used to describe this kind of condition.

Without a doubt, the psychoses have a profound impact on the human world. The number of cases of schizophrenia dealt with by psychiatric services is difficult to gauge because definitions of the disorder have varied from study to study, but estimates of the number of new cases each year from different parts of the world range between around 7 to 40 new cases per 100,000 people⁴ and the figures reported for bipolar disorder are not dissimilar.⁵ The number of people who receive a diagnosis of schizophrenia at any time in their lives is certainly above 0.5 per cent⁶ and, again, about the same estimate has been reported for bipolar disorder.⁷ Taking a broader perspective, it has been calculated that the lifetime risk of suffering from any kind of psychotic disorder may be as high as 3 per cent.⁸ As the current population of Britain is about 60 million people and that of the United States is about 300 million, this means that as many as 1.8 million British citizens and as many as 9 million US citizens may be affected. Extrapolating to the whole world, about 200 million people currently living on the earth are likely to suffer from psychosis at some point in their lives. That is a very large number of people.

The impact of these conditions on quality of life can be gleaned from the fact that, in the developed world, about 5 per cent of schizophrenia patients⁹ and over 7 per cent of bipolar patients commit suicide¹⁰ and many more attempt it. The inability to work or pursue a career is also common. In a recent study of schizophrenia patients in six European countries,¹¹ 41 per cent were judged to be severely disabled when first assessed. Fifteen years later, 25 per cent were still badly disabled. For about two-thirds of these patients their close relationships were affected (many remaining without partners) and about the same proportion were unable to function effectively in the workplace. Once more, a similar picture is evident with respect to bipolar disorder. It has been estimated that a young adult receiving the diagnosis in the United States can expect to lose, on average, nine years of life, twelve years of normal health and fourteen years of employment.¹² To add to this catalogue of misery, the psychoses are also the source of great fear in ordinary people. Selective reporting in the mass media has created the impression that schizophrenia, in particular, is associated with a tendency towards extreme, random violence.¹³

It is, of course, true that psychotic patients, in the grip of their delusions, sometimes commit terrible crimes, although fortunately this happens only rarely. In Britain, a charitable organization called the Zito Trust was set up in 1994 following the senseless slaying of Jayne Zito’s husband Jonathan by Christopher Clunis, a psychiatric patient. On 17 December 1992 Clunis walked up to Zito as he stood waiting for a train at the Finsbury Park Tube station and stabbed him without warning. An official inquiry following the killing revealed that Clunis was well known to local psychiatric services, having been seen by no less than forty-three psychiatrists in five years, and that he had not been detained in hospital despite committing a number of random assaults in the weeks preceding Zito’s death. Against the background of this and similar incidents, many psychiatric services have seen their main role as containment. Surveys carried out in Britain and the United States reveal the widespread use of both informal and formal coercion in the management of people with psychotic illnesses.¹⁴ In Britain and some parts of the United States new legislation allows psychiatrists to compel patients to take their medication on the threat of being detained in hospital if they do not.

Not surprisingly, the financial burdens associated with the psychoses are huge, but vary according to local economic and political conditions. The annual cost of caring for people diagnosed with schizophrenia in the United States has recently been estimated as $22.7 billion¹⁵ and in Britain it has been estimated to be £2.2 billion.¹⁶ However, these direct costs are sometimes dwarfed by the indirect costs accrued through, for example, loss of economic productivity by patients and their carers. The true annual cost of schizophrenia has therefore been estimated at $62.7 billion in the United States and £4 billion in Britain. In many ways, it seems, psychosis is a problem for all of us.

Given these human and financial costs, it is imperative that we bring whatever resources we can muster to address the problems that severe mental illness create for us. We need to find ways of helping those suffering from psychosis to overcome their difficulties, in an attempt to relieve them of their delusions and hallucinations and return them to a full role in society. We need to find ways of supporting their carers – often parents – so that they are not crippled by the emotional and financial burden of looking after their disturbed and often disturbing loved ones. We need to find ways of protecting society from any r...

Table of contents

• Cover Page
• Title Page
• Dedication
• Copyright Page
• Contents
• List of Illustrations
• List of Figures
• Acknowledgements
• Preface: Rational Antipsychiatry
• Part One: An Illusion of Progress
• Part Two: Three Myths about Mental Illness
• Part Three: Medicine for Madness
• Notes
• Index
• Footnote